Soft Tissue Pathology: Gluteal, Hamstrings,

Sports Hernia &Ischiofemoral Impingement

Sandip Biswal, M.D.

Assistant Professor of RadiologyDivision of Musculoskeletal Imaging

Department of RadiologyStanford University School of Medicine

Talk Outline • Anatomy

• Tendons/Muscle

– Gluteus minimus– Gluteus medius– Iliopsoas– Hamstrings– Snapping Hip– Sports Hernia– Ischiofemoral

Impingement

• Nerve-Related Issues– Sciatic– Piriformis Syndrome

Tendon Pathology

Anatomy

Anterior(Gluteus minimus)

Lateral(Gluteus medius)

Posterior

Gluteal anatomy

Dwek et al. MRI Clinics North Am 2005

Pfirrmann et al. Radiology 2001

Gluteal anatomy

Dwek et al. MRI Clinics North Am 2005

Pfirrmann et al. Radiology 2001

Gluteal anatomy

Proc. Intl. Soc. Mag. Reson. Med. 20 (2012)

Tendon Pathology

Rotator Cuff Tear of the HipTendon Pathology

Rotator Cuff Tear of the Hip

Tendon Pathology Rotator cuff tear of the hip

Tendon Pathology Rotator cuff tear of the hip

Tendon Pathology Rotator cuff tear of the hip

Tendon Pathology Small full thickness cuff tear

Proc. Intl. Soc. Mag. Reson. Med. 20 (2012)

Tendon Pathology Small full thickness cuff tear

Tendon Pathology Full thickness cuff tear

Tendon Pathology Full thickness cuff tear

Tendon Pathology Snapping Hip Syndrome

• Sudden, painful audible snapping of the hip which can be reproduced during specific movements of the hip.

• Typically occurs during flexion-abduction-external rotation (frogleg position) to the neutral position.

• Typically observed in athletic individuals.

• DDx– Intra-articular

• Labral tear• Chondral defect• Intra-articular bodies

– Extra-articular• Iliopsoas tendon• Iliofemoral ligament• Iliotibial band !"#$%&'"#(")(%$*(")(%$(+,--./(!"#$

Tendon Pathology Iliopsoas Snapping Hip

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Tendon Pathology Iliopsoas Snapping Hip

Proc. Intl. Soc. Mag. Reson. Med. 20 (2012)

Tendon Pathology External Snapping Hip Syndrome

• Iliotibial band (tensor fascia lata anteriorly and gluteus maximus posteriorly)

• Iliotibial band can be thickened - lies posterior to greater trochanter with extension and snaps forward with flexion

• Thickening and fibrosis of anterior border of gluteus maximus can occur following repeated i.m. injections (vits, analgesics or antibiotics)

• Trochanteric bursitis between iliotibial tract and greater trochanter causes pain and snapping

Normal iliotibial tract

(T2 WI)

Tendon Pathology Bilateral Snapping Hip

Tendon Pathology External Snapping Hip

Tendon Pathology External Snapping Hip, GT bursitis

Tendon Pathology

Iliopsoas Peritendonitis

Proc. Intl. Soc. Mag. Reson. Med. 20 (2012)

Tendon Pathology

Hamstring Anatomy

Primal Pictures Ltd.

Primal Pictures Ltd.

Proximal

hamstrings

20 year oldcross country

runner

Tendon Pathology

Hamstring Tear and

Peritendonitis

Tendon Pathology

Hamstring Tear and

Peritendonitis

19 year old cross country runner

Tendon Pathology

Hamstring Peritendonitis

26 year old marathon runner

Tendon Pathology

Hamstring Peritendonitis and Partial Tear

Proc. Intl. Soc. Mag. Reson. Med. 20 (2012)

Tendon Pathology

Hamstring Tendon Tears/AvulsionTendon Pathology

Hamstring Tendon Tears/Avulsion

Muscle Pathology

Adductor Strain

Tendon Pathology Athletic Pubalgia (Sports Hernia)

• Other names: Sportsman’s hernia, hockey hernia, Gilmore’s groin, osteitis pubis, adductor syndromes.

• Defined as athletic groin pain with multiple etiologies.

• Patients present with pain in the inguinal region. Pain with palpation is present at the external inguinal ring without palpable hernia.

• Opposing interconnected tendinous attachments play a role in pubic symphysis stability (esp. the rectus abdominis and adductor longus). Injury to one tendon leads to injury of the opposing tendon resulting in chronic groin pain.

• Imaging: – Large FOV (28-32 cm to include both hips & ASIS using body coil)

coronal STIR and T1. Ax T2 FSE with FS.– Dedicated smaller 20 cm FOV with surface coil placed at midline for

Obl Ax PD FSE & T2 FSE with FS, Sag T2 FSE with FS.

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Tendon Pathology Athletic Pubalgia (Sports Hernia)

• Differential– Osteitis Pubis– Rectus abdominis strain– Adductor tendon syndromes– Rectus abdominis/adductor aponeurosis injury– Inguinal hernias– Stress fracture (inf pubic ramus)– Hip pathology– Sacroiliitis– etc

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Tendon Anatomy

Athletic Pubalgia

Proc. Intl. Soc. Mag. Reson. Med. 20 (2012)

Tendon Anatomy

Athletic PubalgiaMuscle Pathology

Ischiofemoral Impingement (IFI) Syndrome Abnormal T2 signal in the mid to distal portion of the quadratus femoris muscle with relatively small ischiofemoral space (1.4 cm, normal subjects 2.3 +/- 0.8 cm); these findings may be seen in ischiofemoral impingement syndrome / hip pain.

Muscle Pathology

Radiation-Induced MyositisMuscle-Nerve Pathology

Nerve Anatomy

Muscle-Nerve Pathology

Nerve Anatomy

Pokorny D, Jahoda D et al (2005) Surg Radiol Anat 28(1):88-91

Lee, E. Y. et al. Am. J. Roentgenol. 2004;183:63-64

--40-year-old man with piriformis syndrome

Nerve-Related Pathology

Piriformis Syndrome

Proc. Intl. Soc. Mag. Reson. Med. 20 (2012)

Lee, E. Y. et al. Am. J. Roentgenol. 2004;183:63-64

--40-year-old man with piriformis syndrome

Nerve-Related Pathology

Piriformis SyndromeNerve-Related Pathology

Sciatic Schwannoma

Summary

• Tendons/Muscle

– Gluteus minimus– Gluteus medius– Iliopsoas– Hamstrings– Snapping Hip– Sports Hernia– Ischiofemoral

Impingement

• Nerve-Related Issues– Sciatic– Piriformis Syndrome

I would like to extend a Special Thanks to…

• Kate Stevens, MD• Chris Beaulieu, MD, PhD• Garry Gold, MD• Brian Suh, MD• Samuel Fuller, MD.• Nepenthe Fong, MD

Happy Walking!

Thank you!

for an updated syllabus, please feel free to email me..biswal@stanford.edu

Proc. Intl. Soc. Mag. Reson. Med. 20 (2012)